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The aim of this study is to characterize the presence of exercise oscillatory ventilation EOV and to relate it with other cardiopulmonary exercise test CET responses and clinical variables.

Forty-six male patients age: The EOV was obtained according to Leite et al.

As well, there was no influence ciruegia the presence of EOV on other parameters of CET in this population, suggesting that this variable may be an independent marker of worst prognosis in HF patients. Cardiovascular ischemic events are the leading cause of chronic heart failure CHFwhich is a syndrome that is generally characterized by the classic left ventricular systolic impairment with consequent muscular peripheral dysfunction [ ciurrgia ] caused by not only the low cardiac output, but also by medications, oxidative stress, and chronic hypoxemia, among others [ 2 ].

An important outcome of this peripheral muscular dysfunction is the reduced functional capacity, negatively affecting the patients’ autonomy and consequently their quality of life [ 2 ].

Many parameters are known as independent markers of severity and predictors of morbidity and mortality in this group of patients. The maximal inspiratory pressure brricker been shown as an independent variable to quantify the brixker rate of these patients [ 3 ] because it may reflect the inspiratory muscle weakness, usually witnessed in them.

Furthermore, the handgrip strength has also been reported as an isolated parameter of CHF severity [ 4 ]. In this context, we may highlight the significance of the cardiopulmonary exercise test CET.

It is a useful tool that induce physiological responses in exercise conditions that might not appear at rest conditions. From the parameters obtained in the CET, many of them have been described as negatively influenced by CHF progression. It is quite well known that cirurga with CHF present low functional status and exercise capacity, with reduced bicker oxygen consumption VO 2 [ 56 ]. Also, the presence of oscillatory ventilation in rest or during exercise is being considered as an important variable with prognostic value of CET [ 910 ].

Besides this importance, there is still no standardization for obtaining and interpreting exercise oscillatory ventilation EOV [ 11 ]. Therefore, the aim of the present study is to characterize the presence of EOV and to relate it with other clinical variables in patients with CHF. Cirurgiw men with CHF were recruited by clinical assessment. Inclusion criteria were previous history of stable symptomatic CHF due to left ventricular systolic dysfunction, documented for at least six months left ventricular ejection fraction [LVEF]: No patient had been submitted to cardiovascular rehabilitation.

All subjects presented the same clinical management, optimized medications, and were clinically stable. In the day before the test, patients were brcker to avoid the intake of stimulating drinks, not to perform physical activity, and to have light meals and at least 8 hours of sleep. First, the volunteers were familiarized with the experimental set and involved researchers.

Before the test begun, the patients were examined to verify if the recommendations ciurrgia followed. Then, the systolic and diastolic arterial blood pressure and the peripheral oxygen saturation bricer measured, and it was performed auscultation. For comparative purposes, reference values from Knudson et al.


Carbon monoxide diffusion capacity CMDC was assessed by simple dee model and static volumes were assessed by whole-body plethysmography. Technical procedures and the acceptability and reproducibility criteria ciruegia defined according to norms recommended by the American Thoracic Society [ 14 ]. Ventilatory and metabolic variables were obtained by a computer connected to an ergospirometric measurement system CardiO 2 Systemusing the Breeze Suite 6 software package. Tidal volume was obtained by a Pitot pneumotachometer connected to the CardiO 2 System and attached to a facial mask – which was selected considering the volunteer’s face size and providing an adequate fit in order to avoid air leakage.

The power applied to the cycle ergometer during exercise protocols was controlled by the system through an interface with the bicycle.

Subsequently, three independent observers determined the anaerobic threshold AT under the following situations: The CET data were set from the beginning of the ventilatory and metabolic variables responses to cidurgia output increments till the brickre of the exercise. Analysis of each observer was performed in an independent manner, on a 15 inches monitor SyncMaster V, Samsung connected to the MedGraphics software.

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The presence of periodic breathing was obtained by the analysis of ventilation data, and it was confirmed if there were three consecutive cycles with minimal average amplitude of 5 l in these data peak value minus the average of two in-between consecutive nadirsas suggested by Leite et al. VE and VCO 2 data were analyzed from the beginning of citurgia exercise till peak.

Statistical analyses were performed briker the SigmaPlot version Data were submitted to a normality test Shapiro-Wilk. As a normal distribution was observed, parametric statistical tests were used.

For intergroup comparisons, the t-Student pared test was applied.

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Demographics, anthropometrics, and clinical data were presented as means with standard deviation. Forty-six male patients were recruited; 22 patients were excluded and 24 were included in the present study Figure 1. Table 1 shows age and anthropometric and clinical characteristics of these patients, as well as their functional status and the CET variables with their prognostic thresholds.

Among the 24 included patients, 16 presented EOV. Such analysis was performed to verify if the patients who presented these two concomitant responses had a more severe status than those who didn’t. The present study’s main findings are: Furthermore, they had a poor exercise performance on CET, which can be seen by the value of peak VO 2 The literature shows that CHF patients exhibit a low peak VO 2 [ 16 ] as a marker of exercise intolerance caused by many factors of this disease as the low cardiac output, pulmonary congestion, and alterations of metabolism on peripheral and ventilatory muscle fibers that lead to a muscular dysfunction with impact on exercise tolerance.

Hypotheses for these findings are the heterogeneity of exercise protocols in the literature and the absence of a gold standard to verify the presence of EOV in patients with profile and clinical status similar to our subjects. In a meta-analysis about the assessment of EOV, Cornelis et al.

For the results presented, we used Leite et al. Finally, we believe that Leite et al. From the hemodynamic view, there is an uncoupling on the right ventricle to lung circulation, and a pulmonary edema due to a high ventricle filling pressure even when these patients are clinically stable and on optimized drug therapy [ 20 ].

It suggests the power of EOV as an independent CET marker of worst prognostic because it represents the poor hemodynamic and ventilatory adjust to physical exercise and did not correlate with other ventilatory and metabolic CET variables with prognostic values.


Some studies focused on treatment of EOV and showed that the pathological pattern of ventilation in EOV population can be modulated and even disappear. Three studies evaluating pharmacological therapy with inodilator malrinone [ 23 ] and selective pulmonary vasodilator sildenafil [ 24 ] have shown some attenuation on EOV. These studies evaluated stable patients on optimized drug therapy, which suggests that maybe EOV does not respond to standard treatment for CHF, requiring other approaches than pharmacological interventions, such as physical exercise.

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Based on the present study’s findings, it is important to encourage further studies about EOV in CHF and other patients for a better comprehension of the role of EOV, as well as to establish a gold standard pattern to verify the presence of this variable in different diseases and levels of severity.

Finally, this knowledge improves therapeutic strategies. The absence of gold standard in obtaining EOV must be considered, also some tool to evaluate peripheral muscular strength would give information that could help the interpretation of the findings. Results may not be extrapolated to more severe patients. Finally, this study was made with a convenience sample and more subjects should be recruited to consolidate our findings.

Consequences of exercise-induced respiratory muscle work. Skeletal muscle dysfunction in chronic obstructive pulmonary disease and chronic heart failure: Am J Clin Nutr. Inspiratory muscle training in heart disease and heart failure: Expert Rev Cardiovasc Ther.

Handgrip strength as a predictor of prognosis in Japanese patients with congestive heart failure. Eur J Cardiovasc Prev Rehabil. The clinical and research applications of aerobic capacity and ventilatory efficiency in heart failure: J Am Coll Cardiol.

A meta-analysis of the prognostic significance of cardiopulmonary exercise testing in patients with heart failure. Prognostic value of timing and duration characteristics of exercise oscillatory ventilation in patients with heart failure.

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J Heart Lung Transplant. An overview of the applied definitions and diagnostic methods to assess exercise oscillatory ventilation: Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.

Changes in the normal maximal expiratory flow-volume curve with growth and aging. Am Rev Respir Dis. Standardization of Spirometry, Update. Periodic breathing during incremental exercise predicts mortality in patients with chronic heart failure evaluated for cardiac transplantation.

Revisiting cardiopulmonary exercise testing applications in heart failure: Exerc Sport Sci Rev. Prognostic respiratory parameters in heart failure patients with and without exercise oscillatory ventilation: Exercise oscillatory breathing and increased ventilation to carbon dioxide production slope in heart failure: Oscillatory ventilation during exercise in patients with chronic heart failure: Abnormalities in cardiopulmonary exercise testing ventilatory parameters in heart failure: Curr Heart Fail Rep.

Oscillatory breathing and exercise gas exchange abnormalities prognosticate early mortality and morbidity in heart failure. Treating exercise oscillatory ventilation in heart failure: Periodic breathing during exercise in severe heart failure.

Reversal with milrinone or cardiac transplantation.

Exercise oscillatory ventilation in systolic heart failure: Exercise training reverses exertional oscillatory ventilation in heart failure patients. Brazilian Journal of Bricier Surgery Braz. Sociedade Brasileira de Cirurgia Cardiovascular. Table 1 Anthropometrics, clinical and cardiopulmonary exercise test CET data of the patients included in the present study.

Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; final approval of the version to be published.